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•UpOUR xr <br /> STATE OF CALIFORNIA 4 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> aRR <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L�] 5 CHANGE OF INFORMATION O 7 PERMANENTLY C <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME <br /> NAMEOFOPERATOR <br /> ADDRESS '^^ <br /> • 1G <br /> NEARESTCROSS PAR <br /> CEL 4(OPTIONAL <br /> Z©( :iZ" 5� <br /> CITY NAME STATE CIP <br /> CODE SITE PHONE#WITH AREA CODE <br /> G <br /> 11 PDX CA Y,10 <br /> TOINDCATE O CORPORATION INDIVIDUAL O PARTNERSHIP (]LOCAL-AGENCY O COUNTY-AGENCY E-1 STATE-AGENCY (]FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTORRES✓ERVATION <br /> IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.it(optimal) <br /> O3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA COE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME I CARE OF ADDRESS INFORMATION <br /> ' \C_ L1x S <br /> MAILIN OR STRE TADDRESSC ✓ box blrAkae O INDVDWL LOCAL-AGENCY I�STATE-AGENCY <br /> J I�CORPORATION ID PARTNERSHIP Q COUNTYAGEIKY I� FEDERAL-AGENCY <br /> CITY f \ STATS ZIP CODE HONE 4 WITH AREA CODE <br /> K �q 5 `166 5v - 2q / <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADORESS ✓box 0Wcam D INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY E-3 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4041- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box birdbaA 0 1 SELF-INSURED 2 GUARANTEE 3INSURANCE [7:14 SURETY BOND <br /> O 5 LETTEROFCREDIT Q 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIL"# <br /> r 6 ,OEAoF zo <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONALI it`13 —'12 \ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> _ FOR -5 <br />